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Anesth Analg 2007;104:1059-1065
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000263644.98314.e2

PEDIATRIC ANESTHESIA

Time Course and Prognostic Value of Plasma B-type Natriuretic Peptide Concentration in Neonates Undergoing the Arterial Switch Operation

Maxime Cannesson, MD*, Clara Bionda, MD{dagger}, Bruno Gostoli, MD*, Olivier Raisky, MD, PhD{ddagger}, Sylvie di Filippo, MD, PhD§, Dominique Bompard, MD*, Catherine Védrinne, MD, PhD*, Robert Rousson, MD, PhD{dagger}, Jean Ninet, MD{ddagger}, Jean Neidecker, MD*, and Jean-Jacques Lehot, MD, PhD*

From the Departments of *Anesthesiology and Intensive Care, {dagger}Biochemistry, {ddagger}Cardiac Surgery, and §Pediatric Cardiology, Hospices Civils de Lyon, Louis Pradel Hospital and Claude Bernard Lyon 1 University, Lyon, France.

Address correspondence and reprint requests to Maxime Cannesson, Service d'Anesthésie Réanimation, Hôpital Cardiologique Louis Pradel, 200 avenue du Doyen Lépine, 69500 Bron, France. Address e-mail to maxime_cannesson{at}hotmail.com.


   Abstract
Top
 Abstract
Introduction
 METHODS
 RESULTS
 DISCUSSIONS
 REFERENCES
 
BACKGROUND: Plasma B-type natriuretic peptide (BNP) can predict postoperative complications after cardiac surgery in adults. Our aim was to investigate BNP kinetics and prognostic value in neonates undergoing the arterial switch operation (ASO) for transposition of the great arteries (TGA).

METHODS: We measured BNP concentrations in 30 neonates before, immediately after, and 6, 12, 24, and 48 h after ASO for TGA. Complicated postoperative evolution was defined as patients requiring mechanical ventilation or presenting low cardiac output syndrome for more than 72 h. We studied the ability of postoperative BNP concentrations to predict complicated evolution.

RESULTS: Intubation duration, inotropic support duration, and intensive care unit stay were 68 (48–121) h, 78 (69–141) h, and 96 (76–149) h respectively. Patients with complicated evolution had higher 6 and 12-h BNP concentrations than patients with simple evolution (459 (210–897) vs 137 (67–248) ng/L and 547 (193–868) vs 185 (79–354) ng/L respectively; P < 0.05) and had longer intubation, inotropic support, and intensive care unit stay (96 (70–190) vs 50 (48–66) h, 100 (83–190) vs 70 (59–72) h, and 120 (90–240) vs 84 (72–96) h, P < 0.05). A 6-h BNP concentration >160 ng/L was able to predict complicated evolution with a sensitivity of 93% and a specificity of 67%.

CONCLUSION: In neonates, BNP concentrations can predict adverse outcome in the postoperative period after ASO for TGA. This marker has potential clinical applications.


   Introduction
Top
 Abstract
 Introduction
METHODS
 RESULTS
 DISCUSSIONS
 REFERENCES
 
The arterial switch operation (ASO) has been shown to be the best surgical technique for transposition of the great arteries (TGA) in neonates and has low early and late postoperative mortality (1–3). This technique has to be performed during the first days of life, when the left ventricular mass is sufficient to handle the workload of the systemic circulation. It is a technically challenging procedure, since small coronary arteries have to be transferred to the neoaorta. Consequently, the most common complications after ASO are myocardial ischemia and left and/or right circulatory failure (1–4). In this setting, plasma cardiac Troponin I (cTnI) postoperative increase has been shown to be significantly, but weakly, related to postoperative complications (5–7).

The presence of plasma B-type natriuretic peptide (BNP) was first described in 1988 in. porcine brain (8). This peptide is secreted by both left and right ventricles in response to volume increased ventricular pressure (9). It has been extensively studied in the emergency care setting for differentiating between congestive heart failure and lung disease in patients presenting with acute dyspnea (10–12). More recently, plasma BNP concentrations have been shown to have prognostic value in the postoperative period after cardiac surgery in adults (13–24). Very few studies focusing on plasma BNP concentrations have been conducted in neonates and children (25–31) and little is known about BNP kinetics and prognostic value in the pediatric cardiac surgery setting (32–38). Moreover, most of the studies performed in this population included patients with inhomogeneous ages and diseases (34–37).

The aims of our study were 1) to describe plasma BNP concentrations kinetics in the pre- and postoperative period after ASO for TGA in neonates, and 2) to test the hypothesis that postoperative plasma BNP concentrations are increased in patients with a complicated postoperative course and that it presents a prognostic value in this setting.


   METHODS
Top
 Abstract
 Introduction
 METHODS
RESULTS
 DISCUSSIONS
 REFERENCES
 
Patients
The study protocol was approved by the IRB for human subjects (Comité Consultatif de Protection des Personnes dans la Recherche Biomédicale Lyon B) and all parents gave informed written consent. The patients were prospectively enrolled. Inclusion criteria were patients with simple TGA. Complex TGA was excluded in order to study a population as homogeneous as possible. Simple TGA was defined as TGA with intact ventricular septum and an echocardiographic peak left ventricle-pulmonary artery gradient <50 mm Hg; complex TGA was defined as TGA presenting with interventricular septal defect or Taussig–Bing anomaly (2).

Anesthetic Summary
Preoperative antibioprophylaxis consisted of ceftriaxone 40 mg/kg. Standardized anesthesia was induced using inhaled sevoflurane (6%), sufentanil (0.3 µg/kg), and pancuronium (100 µg/kg) and was maintained with sevoflurane, sufentanil, and pancuronium except during cardiopulmonary bypass (CPB) when midazolam (400 µg/kg) was used instead of sevoflurane.

Surgical Summary
Heparin (300 UI/kg) was administered to maintain an activated clotting time >450 s. Alpha-stat acid–base management was adopted. The ductus arteriosus was ligated at the beginning of the CPB. CPB was routinely conducted (roller pump, disposable membrane oxygenator, and arterial filter) under moderate hypothermia (28°C) and arterial blood pressure was maintained between 30 and 60 mm Hg with flow rates 140–180 mL/kg/min. Myocardial protection was performed with anterograde cold crystalloid cardioplegia. Epinephrine (0.05–0.15 µg/kg/min) and milrinone (0.5–0.75 µg/kg/min, no initial dose) were used systematically for weaning from CPB. Blood was ultrafiltred during CPB to reduce the amount of interstitial edema induced by extracorporeal circulation. In the postoperative period, hemodynamic management was conducted using epinephrine (0.05–0.15 µg/kg/min) and milrinone (0.5– 0.75 µg/kg/min). Intravascular volume expansion was conducted according to the attending physician and consisted of 20% human albumin or fresh-frozen plasma. Diuretics consisted of IV furosemide infusion (1–10 mg/kg/day). After surgical repair, all patients were admitted to the intensive care unit (ICU).

Biological Procedure
Blood samples were collected preoperatively (immediately after anesthetic induction) and in the ICU immediately after admission, and then 6, 12, 24, and 48 h after surgery (preoperative, H0, H6, H12, H24, and H48 respectively). Blood samples were collected into tubes containing potassium EDTA (1 mg/mL blood) and centrifuged within 60 min. The plasma fraction was stored at –80°C until analysis. Within 8 wk of obtaining samples, plasma was thawed to room temperature, and BNP concentrations were determined on site. Plasma cTnI concentrations were determined on Access2 (Beckman-Coulter, Fullerton, CA) (reference value: cTnI ≤0.1 µg/L). BNP concentrations were measured with the BNP Triage test (Biosite, San Diego, CA), on the Immunoassay System Access2 (Beckman-Coulter) for quantitative measurement, in EDTA plasma specimens. The Triage BNP test on Access 2 is a chemiluminescent-immunoenzymatic assay, with two antibodies (monoclonal and omniclonal) against human BNP. Precision, analytical sensitivity, and stability characteristics of the system have been described (39). In brief, in our study, the coefficient of variation for total imprecision was of 2.8% and 2.1% for the BNP levels of 388 ng/L and 2079 ng/L respectively, and the with-run imprecision was 1.7% and 1.2% for the BNP levels of 85.1 ng/L and 1343 ng/L respectively. The measurable range of BNP assay on Access2 was 1.0–5000 ng/L.

The following clinical data were recorded: CPB time, aortic cross-clamping time, intubation duration, inotropic support by catecholamine duration, length of ICU stay, and peak left atrial pressure (LAP), defined as the maximum LAP value over the first 48 h after surgery. Low cardiac output syndrome was defined using Hoffman et al.'s criterion (40,41). Patients were diagnosed with low cardiac output syndrome if they demonstrated clinical signs and symptoms of the syndrome (such as tachycardia, oliguria, cold extremities, or cardiac arrest), with or without a ≥30% difference in arterial-mixed venous oxygen saturation or metabolic acidosis (an increase in the base deficit of >4 or an increase in the lactate of >2 mg/dL) on two successive blood gas measurements or administrations of interventions aimed at increasing cardiac output (increased pharmacologic support compared to baseline and mechanical pacing). (41) All clinical data were collected by an investigator blinded for plasma BNP concentrations.

Statistical Analysis
Data are presented as median (interquartile range). We used a previously published study (32) to determine the number of patients to be included. In this study focusing on pediatric cardiac surgery patients, the authors found a H12 plasma BNP concentration of 170 ± 28 ng/L. Assuming a {alpha} risk of 0.05, a ß risk of 0.10, a ratio between simple and complicated postoperative evolution and of 1:1, and a mean difference of 20%, we calculated that 30 patients should be included in this study. Data were analyzed using nonparametric Mann–Whitney U-test or Wilcoxon test as appropriate. Spearman rank method was used to test linear correlation. The time course of BNP concentration was tested by ANOVA for repeated measures followed by a Bonferroni post hoc test. Because of their non-normal distribution, plasma BNP concentrations were log transformed when appropriate. Patients were then divided in two groups according to the predefined following criterion: patients with simple postoperative evolution and patients with complicated postoperative evolution defined as patients requiring more than 72 h of ventilation or presenting low cardiac output syndrome for more than 72 h (4). Receiver operating characteristic (ROC) curves were generated for BNP and cTnI concentrations varying the discriminating threshold of each parameter and area under the ROC curves were calculated and compared (42) (MedCalc 8.0.2.0, MedCalc Software, Mariakerke, Belgium). A P value <0.05 was considered statistically significant. All statistical analyses were performed using SPSS 13.0 for Windows, SPSS, Chicago, IL.


   RESULTS
Top
 Abstract
 Introduction
 METHODS
 RESULTS
DISCUSSIONS
 REFERENCES
 
We studied 30 consecutive neonates (aged 3–26 days, 21 males) who were referred for ASO for simple TGA between December 2004 and February 2006. Twenty-four patients received prostaglandin E1 before surgery in order to maintain patency of ductus arteriosus and percutaneous balloon atrioseptostomy was performed in 19 patients. Over the same period of time, four patients were excluded because of complex TGA.

Clinical Results
There was no death up to 1 mo after surgery. No patients received extracorporeal membrane oxygenation, modified ultrafiltration or deep hypothermic circulatory arrest. Complicated postoperative evolution was observed in 15 patients (Table 1). These patients presented significantly longer aortic cross-clamping duration [93 (77–104) vs 71 (67–81) min; P < 0.05] and higher peak LAP over the first 72 h after surgery [15 (11–15) vs 11 (10–12) mm Hg; P < 0.05]. As expected, patients presenting with complicated postoperative evolution had longer intubation duration [96 (70–190) vs 50 (48–66) h; P < 0.01], inotropic support duration [100 (83–190) vs 70 (59–72) h; P < 0.01], and ICU stay [120 (90–240) vs 84 (72–96) h; P < 0.01].


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  		Table 1. Differences in Demographic Data Between Patients with Complicated Postoperative Evolution and Patients with Simple Postoperative Evolution

 

Time Course of Plasma BNP and cTnI Concentrations
Plasma BNP Concentrations
Interestingly we found a strong and significant inverse relationship between weight before surgery and preoperative BNP concentrations (r = –0.63; P < 0.001). There was no relationship between preoperative BNP concentration and age (r = 0.11; P = 0.56), and no difference in preoperative BNP concentrations with gender (P = 0.62). We observed a significant decrease in plasma BNP concentrations between preoperative values and H0 (from 198 (61–518) to 122 (46–200) ng/L; P < 0.05) followed by a significant increase between H0 and H6 (from 122 (46–200) to 228 (94–493) ng/L; P < 0.05). Thereafter, we observed no significant change in plasma BNP concentrations until H48 (Table 2).


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  		Table 2. Perioperative Plasma B-type Natriuretic Peptide and Cardiac Troponin I Concentrations

 

Plasma cTnI Concentrations
We observed a significant increase in cTnI concentrations from preoperative values to H0 (from 0.03 (0.02– 0.07) to 7.6 (6.7–13.5) µg/L; P < 0.001) followed by a plateau between H0 and H12 and then a significant decrease from H12 to H24 (from 8.6 (6.9–12.8) to 5.2 (3.4–9.4) µg/L; P < 0.001) and from H24 to H48 (from 5.2 (3.4–9.4) to 2.4 (1.5–3.9) µg/L; P < 0.001) (Table 2).

Prognostic Value of Plasma BNP and cTnI Concentrations
H6 and H12 plasma BNP concentrations were significantly higher in patients with complicated postoperative evolution compared to patients with simple evolution [459 (210–897) vs 137 (67–248) ng/L and 547 (193–868) vs 185 (79–354) ng/L respectively; P < 0.05 for both] (Fig. 1) (Table 3). There was a statistically significant positive relationship between H6 plasma BNP concentration and intubation duration (r = 0.57; P < 0.01), inotropic support duration (r = 0.54; P < 0.01), and ICU stay (r = 0.59; P < 0.01). Similarly, H12 plasma BNP concentration was significantly related to intubation duration (r = 0.57; P < 0.01), inotropic support duration (r = 0.55; P < 0.01), and ICU stay (r = 0.53; P < 0.01). We observed no statistically significant differences in preoperative, H0, H6, H12, and H24 cTnI concentrations between patients with complicated postoperative evolution and those with simple evolution. However, H48 cTnI concentration was higher in patients with complicated evolution [2.8 (1.7–6.7) vs 1.9 (1.4–2.7) µg/L; P < 0.05]. H48 plasma cTnI concentration was weakly but significantly correlated to intubation duration (r = 0.37; P < 0.05), inotropic support duration (r = 0.37; P < 0.05), but not to ICU stay (r = 0.35; P = 0.54).


Figure 112
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  		Figure 1. Box plots showing plasma B-type natriuretic peptide (BNP) concentrations evolution before and after cardiopulmonary bypass in patients with simple and complicated postoperative evolution. Boxes show the interquartile range and I-bars show the extreme values. Plasma BNP concentrations were log-transformed because of their non-normal distribution (preoperative value, H0, H6, H12, H24, and H48 are respectively immediately, 6, 12, 24, and 48 h after surgery. *P < 0.05 compared to simple postoperative evolution).

 

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  		Table 3. Plasma BNP Concentration in Patients with Simple and Complicated Postoperative Evolution

 

For prediction of complicated postoperative evolution, H6 plasma BNP concentration had the higher area under the curve among the variables for which we observed significant differences between patients with simple and complicated postoperative evolution (Table 4) (Fig. 2). A plasma BNP concentration more than 160 ng/L 6 h after surgery allowed the prediction of an ICU complicated course with a sensitivity of 93% and a specificity of 67%.


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  		Table 4. Areas of Receiver-Operating Characteristic Curves for the Prediction of Complicated Postoperative Evolution After Arterial Switch Operation for Transposition of the Great Arteries in Neonates

 

Figure 212
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  		Figure 2. ROC curves comparing the ability of 6-h (H6) plasma B-type natriuretic peptide (BNP) concentration, 12-h (H12) BNP concentration, 48-h (H48) plasma cardiac troponin I (cTnI) concentration, and peak left atrial (LAP) pressure over the first 72 h to discriminate between patients with simple and complicated postoperative evolution.

 


   DISCUSSIONS
Top
 Abstract
 Introduction
 METHODS
 RESULTS
 DISCUSSIONS
REFERENCES
 
This is the first study to focus on the perioperative BNP plasma concentrations in neonates undergoing ASO for TGA. Our results show that postoperative BNP concentrations can predict complicated postoperative evolution with satisfactory sensitivity and specificity in this population.

We chose to study neonates undergoing ASO for simple TGA because this is a homogenous population with a stereotypical postoperative period. Our findings regarding intubation duration, inotropic support duration and ICU stay are consistent with previously published results (4). ASO is the technique of choice for the management of neonates with TGA. It has been shown to have low early and late postoperative complications (1–4). However, this surgical procedure is responsible for acute and dramatic changes in right and left ventricular loading conditions (4). After its connection to the aorta, the left ventricle has to handle the workload of the systemic circulation. This sudden change is often responsible for left ventricular failure and inotropic requirement. It is therefore important to predict postoperative low cardiac output syndrome. In this setting, few indices have a prognostic value. Imura et al. (5) showed that a peak postoperative cTnI concentration is weakly, but significantly, correlated with clinical outcome (duration of inotropic support, intubation, and ICU stay) in this population. In all studied pediatric cardiac surgery patients, cTnI has also been shown to predict adverse postoperative outcomes (6,7). The results of our study are consistent with these previously published data. We found that early postoperative cTnI concentrations were weakly correlated to duration of intubation, inotropic support, and ICU stay. Moreover, we were not able to define a threshold value allowing discrimination between patients with complicated postoperative evolution from those with simple evolution.

BNP has been extensively studied in adults. This peptide is secreted by both left and right ventricles in response to volume increased ventricular pressure (9). It was first described for differentiating between congestive heart failure and lung disease in patients presenting with acute dyspnea in the urgent-care setting (10–12). In adult cardiac surgery patients, perioperative plasma BNP concentrations have also been studied (13–24) and have been shown to have satisfactory prognostic value. Most of these studies describe perioperative BNP release similar to the one observed in our neonatal population. The BNP concentration increases at 12 and 24 postoperative hours (13,16,18,20) and normalization occurs at 2 or 3 postoperative weeks (16).

In the pediatric cardiac surgery setting, BNP has been less extensively studied (32,34–38). All of these studies except one (32) found a significant increase in plasma BNP concentrations on the first postoperative day. Interestingly, Ationu et al. (32) found a decrease in BNP concentration immediately after CPB. Our data are consistent with these observations and extend the results of other studies focusing on cardiac surgery in children. We found that BNP concentration significantly decreases immediately after surgery compared to preoperative values, and that it increases significantly 6 and 12 h after surgery. We cannot conclude whether these changes are clinically significant. However, we observed that the changes in BNP concentrations at H6 from baseline in patients with complicated evolution are larger than those observed in patients with simple evolution (Tables 2 and 3). As we did not measure BNP levels after the 48th postoperative hour we cannot make conclusions about its normalization.

Interestingly, Costello et al. (35) found an increase in postoperative plasma BNP concentration related to CPB time in children and suggested that it should be studied as a predictor of postoperative morbidity. Recently, Shih et al. (37) studied the prognostic value of BNP concentrations in pediatric cardiac surgery patients undergoing biventricular repair. They found that BNP concentration larger than 540 ng/L 12 h after surgery had predictive value for detecting patients with prolonged mechanical ventilation and low cardiac output syndrome. These results are important, since they were the first to describe the prognostic value of BNP in this setting. However, the cohort of patients studied was inhomogeneous concerning cardiac diseases and ages (ages ranged from 1 to 5655 days in this study). Another recent study by Mir et al. (38) failed to find any significant relationship between perioperative BNP concentrations and clinical outcome (catecholamine duration and dosage, intubation duration). However, they included a wide range of pathologies (including biventricular and single ventricular repair) and ages and did not measured BNP concentrations at 6 and 12 postoperative hours that seem to be the best predictors of clinical outcome according to Shih et al.'s study (37) and to our present data. In our homogenous cohort of patients, we found that H6 and H12 BNP concentrations were both significantly correlated to clinical outcomes and were significantly higher in patients with complicated postoperative evolution. Moreover, the H6 BNP concentration >160 ng/L had a good predictive value for identifying these patients.

These results are in agreement with previously published data showing that low cardiac output syndrome occurs around the 12th hour in neonates undergoing ASO (4). Thus, plasma BNP concentration could be used clinically to predict a complicated postoperative course. This test is easy to perform and the result is rapidly available since it has been developed in the emergency care setting (39). We think that it may help clinicians in daily practice. Until now, there were no criteria for mechanical ventilation weaning in neonates undergoing ASO and the decisions were made on an individual basis. We can postulate that BNP concentration may help clinicians in the decision making process regarding tracheal extubation, inotrope management, and ICU discharge. However, further studies are required to answer these questions.

We observed wide ranges of values and significant overlap between patients with a simple and complicated postoperative course. This observation was not related to anesthetic management, since it was uniform among patients. Other studies focusing on BNP in congenital cardiac surgery found similar non-normal distribution (37,38). The cutoff value in our sample of patients is lower than the one described by Shih et al. (160 ng/L in our study vs 540 ng/L in Shih et al. study) (37). We can postulate that this discrepancy is the result of the differences between the two studied populations. This underlines the importance to study homogeneous cohorts of patients in the neonatal and pediatric cardiac surgery setting. We chose to focus on patients with simple TGA because this is the most frequent anatomical form of TGA (43). Sun et al. studied patients with biventricular cardiac defects and patients with univentricular cardiac defects. They observed a significant increase in postoperative BNP concentration in patients with biventricular cardiac defects, but not in patients with univentricular cardiac defects (36). This observation emphasizes the importance of studying homogeneous samples of patients.

Another important finding is that preoperative plasma BNP concentrations were significantly related to weight. We found an inverse correlation between log BNP concentration and weight before surgery. Very little is known about plasma BNP concentrations in healthy neonates. However, most of the studies focusing on the subject describe an increase in plasma BNP concentrations during the first days of life with a normalization occurring around the second week after birth (28–30). Shih et al. also found an inverse relationship between preoperative BNP concentrations and weight in their sample of patients (37).

The mechanisms underlying the increase in BNP concentrations after cardiac surgery are poorly understood. We can postulate that both myocardial ischemia and changes in ventricular loading conditions are responsible for these variations. BNP has been shown to increase during myocardial ischemia, even in the absence of ventricular failure (44). Moreover, an acute increase in left ventricular afterload after ASO can contribute to these changes. As TnIc has poor predictive value of low cardiac output syndrome, it can be postulated that this complication is linked with poor cardiac adaptation to loading conditions rather than to myocardial injury. However, further studies are required to explore the reasons for these changes.

Study Limitations
We chose to focus on a homogeneous cohort of patients. Consequently, our results cannot be extrapolated to other situations. However, pediatric cardiac surgery is so heterogeneous that it is of major importance to focus on specific subgroups of patients. As suggested by our results and those of others, plasma BNP concentrations depend on age and weight (28–30,37) as well as on cardiopathy (27,36). Consequently, when evaluating BNP's kinetic and prognostic value this heterogeneity should be considered. Another limitation is that we did not measure cardiac output invasively in our patients, but defined low cardiac output syndrome using clinical and biological variables. This methodology has been described previously and has already been used in numerous other studies (40).

In conclusion, the results of our study show that plasma BNP concentrations significantly increase in the postoperative period after ASO for TGA in neonates, despite wide ranges of values. H6 and H12 plasma BNP concentrations are correlated to clinical indicators (intubation duration, inotropic support duration, and ICU stay) despite significant overlap. A H6 plasma BNP concentration more than 160 ng/L can predict complicated postoperative evolution with a sensitivity of 93% and a specificity of 67%. The postoperative BNP concentration has better predictive value than cTnI concentration.


   Footnotes
 
Accepted for publication January 23, 2007.


   REFERENCES
Top
 Abstract
 Introduction
 METHODS
 RESULTS
 DISCUSSIONS
 REFERENCES
 

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